title: Trends in insulin initiation and treatment intensification among patients with type 2 diabetes.
abstract: BACKGROUND
  Many patients with type 2 diabetes eventually require insulin, yet little is known about the patterns and quality of pharmacologic care received following insulin initiation. Guidelines from the American Diabetes Association and the European Association for the Study of Diabetes recommend that insulin secretagogues such as sulfonylureas be discontinued at the time of insulin initiation to reduce the risk of hypoglycemia, and that treatment be intensified if HbA1c levels remain above-target 3 months after insulin initiation.
  
  
  OBJECTIVE
  To describe pharmacologic treatment patterns over time among adults initiating insulin and/or intensifying insulin treatment.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  A large commercially insured population of adult patients without recorded type 1 diabetes who initiated insulin.
  
  
  METHODS
  We evaluated changes in non-insulin antidiabetic medication use during the 120 days immediately following insulin initiation, rates of increase in insulin dose and/or dosing frequency during the 270 days following an insulin initiation treatment period of 90 days, and rates of insulin discontinuation.
  
  
  RESULTS
  Seven thousand, nine hundred and thirty-two patients initiated insulin during 2003-2008, with the majority (61 %) initiating basal insulin only. Metformin (55 %), sulfonylureas (39 %), and thiazolidinediones (30 %) were commonly used prior to insulin initiation. Metformin was continued by 64 % of patients following mixed or mealtime insulin initiation; the continuation rate was nearly as high for sulfonylureas (58 %). Insulin dose and/or dosing frequency increased among 22.9 % of patients. Insulin was discontinued by 27 % of patients.
  
  
  CONCLUSIONS
  We found evidence of substantial departures from guideline-recommended pharmacotherapy. Insulin secretagogues were frequently co-prescribed with insulin. The majority of patients had no evidence of treatment intensification following insulin initiation, although this finding is difficult to interpret without HbA1c levels. While each patient's care should be individualized, our data suggest that the quality of care following insulin initiation can be improved.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA, arpatrick@partners.org.
authors.forename: Amanda R
authors.initials: AR
authors.lastname: Patrick
authors.forename: Michael A
authors.initials: MA
authors.lastname: Fischer
authors.forename: Niteesh K
authors.initials: NK
authors.lastname: Choudhry
authors.forename: William H
authors.initials: WH
authors.lastname: Shrank
authors.forename: John D
authors.initials: JD
authors.lastname: Seeger
authors.forename: Jun
authors.initials: J
authors.lastname: Liu
authors.forename: Jerry
authors.initials: J
authors.lastname: Avorn
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Polinski
mesh_terms: D000293:Adolescent; D000328:Adult; D054598:Blue Cross Blue Shield Insurance Plans / Q000639:trends*; D015331:Cohort Studies; D016208:Databases, Factual / Q000639:trends*; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007328:Insulin / Q000008:administration & dosage*; D008137:Longitudinal Studies; D008297:Male; D008687:Metformin / Q000008:administration & dosage; D008875:Middle Aged; D009515:New Jersey / Q000453:epidemiology; D017410:Practice Guidelines as Topic / Q000592:standards; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin; D008687:Metformin